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Table of Content

    01 March 2026, Volume 17 Issue 2
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    Original Articles
    Prediction model for quality of life in sepsis survivors one year after discharge Open Access
    Yi Yao, Wenjin Li, Dejiang Hong, Ze Chen, Kai Peng, Guangju Zhao
    2026, 17(2):  105-112.  doi:10.5847/wjem.j.1920-8642.2026.015
    Abstract    HTML    PDF (538KB)   

    BACKGROUND: Sepsis survivors experience poor long-term quality of life post-discharge. The aim of this study was to analyze the factors that impact the long-term quality of life of sepsis survivors and develop a clinical prediction model.

    METHODS: A total of 442 sepsis patients from the Emergency Intensive Care Unit of a tertiary hospital in Wenzhou were included. These patients were assigned to the training set or the validation set at a ratio of 7:3. The European Quality of Life 5 Dimensions 5 Level Version (EQ-5D-5L) questionnaire was used to evaluate the quality of life in sepsis survivors one year after discharge. Multivariate logistic regression analysis was used to identify predictors, which were then used to develop the prediction model and subsequently derive a scoring system. The model's effectiveness was assessed using an area under the receiver operating characteristic curve, calibration curves, and clinical decision analysis.

    RESULTS: Of the 442 patients included, 70 died one year after discharge, and 372 completed the questionnaire. A total of 46.6% of sepsis survivors have poor quality of life one year after discharge in the training set. Multivariate logistic regression revealed that age, platelet, serum albumin, serum urea, and C-reactive protein were independent risk factors for poor quality of life in sepsis survivors. The area under the curve of the scoring system was 0.777 (95% CI: 0.726-0.828). The calibration curves showed that it was well calibrated. Decision curve analysis indicated that the scoring system provided good clinical usefulness. The internal validation also demonstrated its effectiveness.

    CONCLUSION: The prediction model incorporating five risk factors may predict quality of life one year after discharge in sepsis survivors, which provides a measure to develop post-discharge rehabilitation and follow-up plans for this patient population.

    Role of NRF2 in regulating oxidative stress and alleviating mitochondrial and endoplasmic reticulum structural damage in heatstroke-induced brain injury Open Access
    Bingling Yin, Haiyang Guo, Yu Shao, Chongxiao Xu, Yueli Zhao, Ting Chen, Xuan He, Shan Sun, Caoyuan Wu, Guodong Lin, Zhiguo Pan
    2026, 17(2):  113-125.  doi:10.5847/wjem.j.1920-8642.2026.026
    Abstract    HTML    PDF (2950KB)   

    BACKGROUND: he central nervous system is a critical target of severe heatstroke, with oxidative stress and multi-organelle damage being the key pathogenic mechanisms. However, research on endogenous antioxidant defense remains limited. In this study, we aimed to characterize neuronal oxidative damage as a key heatstroke pathological mechanism and assess the neuroprotective effects of nuclear factor E2-related factor 2 (NRF2).

    METHODS: After developing in vivo and in vitro heatstroke models, we employed histological staining, cell viability and apoptosis assays, oxidative stress indicators determination, organelle ultrastructural observation, and molecular expression analysis to investigate the mechanisms of brain injury and changes in the NRF2 pathway following heatstroke. We pretreated mice and SH-SY5Y cells with tert-butylhydroquinone (TBHQ) to activate NRF2 expression. Furthermore, we utilized NRF2 knockout (KO) mice and NRF2 siRNA transfection to suppress NRF2 expression, thereby examining the effects of NRF2 both in vivo and in vitro.

    RESULTS: We found that heatstroke induced neuronal damage, elevated oxidative stress levels, and caused structural damage to both the mitochondria and the endoplasmic reticulum (ER). Notably, NRF2 activation was insufficient post-heatstroke. Pretreatment with TBHQ effectively activated the NRF2 signaling pathway and mitigated the resulting damage. In contrast, these injuries were exacerbated in NRF2 KO mice and SH-SY5Y cells transfected with NRF2 siRNA.

    CONCLUSION: This preliminary research shows that the NRF2 antioxidant signaling pathway exerts a protective effect against oxidative stress, mitigating both mitochondrial and ER structural damage in neuronal cells during heatstroke. Therefore, targeting the NRF2 pathway is a promising therapeutic strategy for heatstroke-induced neuronal injury.

    The basal forebrain-DMN/solv cholinergic projection mediates the attenuation of brain injury after cardiopulmonary resuscitation Open Access
    Senlin Xia, Zumin Chen, Yanmei He, Yanhan Yang, Mingyang Qin, Lizhao Xu, Hui Peng, He Liu, Sheng Qiu, Lijun Liu
    2026, 17(2):  126-136.  doi:10.5847/wjem.j.1920-8642.2026.027
    Abstract    HTML    PDF (4930KB)   

    BACKGROUND: To investigate the mechanism underlying the basal forebrain-DMN/solv cholinergic projection-induced attenuation of brain injury after cardiopulmonary resuscitation (CPR).

    METHODS: Forty-six male Sprague‒Dawley rats were randomly divided into five groups: the sham group (n=6), the return of spontaneous circulation (ROSC) group (n=10), the optogenetic activation (CHAT-Light-CHR2) group (n=10), the optogenetic inhibition (CHAT-Light-NpHR) group (n=10), and the optogenetic activation combined with left cervical vagotomy (CHAT-Light-CHR2 + LcVGX) group (n=10). Excitatory (CHR2) or inhibitory (NpHR) optogenetic viruses were injected into the basal forebrain (BF) of rats, followed by the implantation of ceramic ferrules. After three weeks of viral expression, the sham group received tracheotomy and catheterization only, the ROSC group underwent tracheotomy, asphyxial cardiac arrest, and CPR, and the CHR2 and NpHR groups received post-ROSC optogenetic activation or inhibition, respectively. The CHAT-Light-CHR2 + LcVGX group was pretreated with left cervical vagotomy followed by post-ROSC activation. Post-ROSC assessments included neurofunctional deficit score (NDS), histopathology (HE/Nissl/TUNEL staining and CD11b microglial activation) in the hippocampal CA1/prefrontal cortex, serum cytokines (IL-1β, IL-6 and TNF-α), and whole-brain immunofluorescence (c-Fos/CHAT) for neuronal activation mapping.

    RESULTS: Compared with the rats of sham group, rats of the ROSC group presented reduced NDS, neuronal loss, increased apoptosis, elevated CD11b expression, and increased cytokine levels. CHAT-CHR2 activation improved NDS, reduced neuronal loss and apoptosis, and decreased CD11b expression and TNF-α levels. CHAT-NpHR inhibition caused no improvement in NDS but exacerbated neuronal loss and CD11b expression elevation. CHAT-CHR2+LcVGX reversed these protective effects. Whole-brain immunofluorescence staining revealed that optogenetic activation of cholinergic neurons in the BF of the CHAT-Light-CHR2 group excited neurons in the DMN/solv region, which were identified as dopaminergic neurons.

    CONCLUSION: Cholinergic projections from the basal forebrain-DMN/solv may alleviate systemic and neuroinflammatory responses through the cholinergic anti-inflammatory pathway and mitigate brain injury following CPR.

    Association between on-scene cardiopulmonary resuscitation duration and outcomes in out-of-hospital cardiac arrest patients Open Access
    Sohyeon Chun, Gi Woon Kim, Han Bit Kim
    2026, 17(2):  137-145.  doi:10.5847/wjem.j.1920-8642.2026.030
    Abstract    HTML    PDF (528KB)   

    BACKGROUND: Prolonged on-scene Advanced Life Support (ALS) in out-of-hospital cardiac arrest (OHCA) patients may enhance return of spontaneous circulation (ROSC), but the optimal duration of cardiopulmonary resuscitation (CPR) without initial prehospital ROSC remains unclear. We investigated the association between on-scene CPR duration and outcomes using nationwide data.

    METHODS: This prospective, multi-regional study (2015-2022) included medical cause OHCA patients who underwent Smart ALS (SALS). Data from emergency medical services (EMS) records, SALS logs, and hospital outcomes were analyzed. Logistic regression models were developed for prehospital ROSC, survival to discharge, and good neurological outcome (Cerebral Performance Category [CPC] 1-2).

    RESULTS: Among 98,569 patients, 34,989 were SALS-eligible and 16,052 received SALS. Predictors of ROSC included younger age, male sex, public arrest, witnessed arrest, bystander CPR, shockable rhythm, and shorter response/scene times. Longer on-scene CPR reduced probabilities of ROSC, survival, and neurological recovery at hospital discharge. Model AUROCs were 0.697 (95%CI 0.676-0.717) for ROSC, 0.836 (95%CI 0.810-0.861) for survival, and 0.925 (95%CI 0.904-0.946) for neurological outcome.

    CONCLUSION: On-scene CPR duration is a critical prognostic factor in OHCA. The proposed models highlight on-scene predictors that may inform decisions about CPR continuation and support individualized resuscitation strategies. External validation in other EMS systems is warranted.

    Indications, techniques, success rates and complications of emergency airway management in Thuringian emergency departments: a prospective registry analysis Open Access
    Nelly Richter, Frank Bloos, Christian Hohenstein
    2026, 17(2):  146-153.  doi:10.5847/wjem.j.1920-8642.2026.033
    Abstract    HTML    PDF (416KB)   

    BACKGROUND: Airway management is a core competence in emergency medicine. International registries have described indications, techniques, and outcomes of endotracheal intubation, yet contemporary data from German emergency departments (EDs) are scarce. We conducted a multicenter prospective registry study in Thuringia, to characterize indications, techniques, success rates, and complications of ED intubations.

    METHODS: From February 2023 to January 2024, six Thuringian EDs participated in a prospective observational registry (www.airwayregistry.eu). All consecutive intubations were documented anonymously using a standardized digital form. Demographics, indications, methods, equipment, operator characteristics, first pass success (FPS), overall success, and complications were captured. Descriptive statistics were used.

    RESULTS: We analyzed 117 intubations (63.2% male; mean age 68.4 years, range 2-98 years). FPS was 88.9% (104/117), second pass success was 4.3% and third pass success was 6.8%; overall success was 100%. Rapid sequence intubation (RSI) was used in 77.8% of intubations and delayed sequence intubation (DSI) in 21.4%; 10.3% were performed without medication. Direct laryngoscopy (DL) was used in 65.0% and videolaryngoscopy (VL) in 34.2%. FPS was higher with VL than DL (92.5% vs. 88.2%). The most common indications were cardiopulmonary resuscitation (14.5%) and stroke/ischemia (13.7%); intracranial hemorrhage accounted for 13.7%. Complications occurred in 39% of cases, most frequently hypotension (23.9%) and catecholamine requirement (12.0%). A difficult airway was anticipated in 30.8%.

    CONCLUSION: In this multicenter snapshot from German EDs, overall intubation success was high but complications—especially peri-intubation hypotension—were common. VL yielded higher FPS yet was used less frequently than DL. Standardized protocols, hemodynamic optimization, and broader VL adoption may improve safety and performance.

    The Brazilian risk assessment severity index score: a novel tool for predicting in-hospital mortality in emergency departments Open Access
    Paulo Henrique Reis Negreiros, Mariana Rebello Hilgert, Bruno Guerra, Maurício de Carvalho, Hugo Manuel Paz Morale, Gustavo Lenci Marques
    2026, 17(2):  154-161.  doi:10.5847/wjem.j.1920-8642.2026.036
    Abstract    HTML    PDF (734KB)   

    BACKGROUND: Rapid identification of patients at risk of clinical deterioration (in-hospital mortality) in emergency settings is essential for timely and appropriate care. Existing prognostic scores, such as the Acute Physiology and Chronic Health Evaluation IV (APACHE IV), Simplified Acute Physiology Score 3 (SAPS 3), Sequential Organ Failure Assessment (SOFA), and National Early Warning Score 2 (NEWS 2), have limitations in emergency scenarios, particularly in resource-limited settings. We aimed to develop a simple and efficient tool tailored to the Brazilian healthcare system.

    METHODS: This retrospective, multicenter, cohort study analyzed data from 50,709 adult patients admitted to 12 hospitals in southern and southeastern Brazil between 2019 and 2020. The BRASIL score (Brazilian Risk Assessment Severity Index and Length of stay) was constructed using demographic and clinical variables available at admission. Logistic regression was used to determine the weight of each variable, and each variable was assigned a point value based on its β-coefficient and clinical relevance, with thresholds defined according to established medical cutoffs and statistical performance. The score’s predictive accuracy was validated using the area under the receiver operating characteristic curve (AUC) with comparative analysis against NEWS 2.

    RESULTS: The BRASIL score, including age, sex, respiratory rate, heart rate, oxygen saturation, blood pressure, and body temperature, was derived through variables independently associated with in-hospital mortality in a multicenter cohort. The total score was stratified into three risk categories — low (0-3 points), moderate (4-7 points), and high (>7 points) — using observed inflection points in mortality distribution to optimize discrimination. This stratification demonstrated a stepwise increase in mortality rates across categories and the discriminatory performance, with an overall AUC of 0.743 (95% CI: 0.726-0.761). Compared to NEWS 2 (AUC 0.697, 95% CI: 0.683-0.711), the BRASIL score offered superior early risk identification, supporting timely clinical decision-making and resource allocation in the emergency setting.

    CONCLUSION: The BRASIL score is a novel tool for predicting in-hospital mortality in emergency departments. Its predictive performance and ease of use suggest that it has the potential to improve patient outcomes.

    Single-cell transcriptomics reveals pathogen-specific monocyte heterogeneity and potential biomarkers in gram-positive versus gram-negative bloodstream infections
    Jinlan Ma, Li Peng, Hongming Yu, Jianfeng Xie, Ying Tang, Shenglin Su, Libing Ma, Xiaojun Yang
    2026, 17(2):  162-171.  doi:10.5847/wjem.j.1920-8642.2026.035
    Abstract    HTML    PDF (1313KB)   

    BACKGROUND: Bloodstream infections (BSIs) caused by gram-positive cocci (GPC) and gram-negative bacilli (GNB) are major causes of sepsis. However, their distinct effects on host responses remain poorly characterized at the single-cell level. This study used single-cell transcriptomics to define pathogen-specific monocyte heterogeneity in BSIs to identify the mechanisms underlying clinical differences.

    METHODS: Single-cell RNA sequencing (scRNA-seq) was performed on peripheral blood mononuclear cells obtained from healthy volunteers, two patients with GNB-BSI sepsis, and two patients with GPC-BSI sepsis. Differential gene expression, particularly in monocytes, was analyzed. The key findings were validated with clinical characteristics and outcomes of 45 patients with GNB-BSI sepsis and 40 patients with GPC-BSI sepsis. The distinguishing performances of identified biomarkers were evaluated via receiver operating characteristic (ROC) curve.

    RESULTS: In pathogen-specific transcriptomes, 54 identified genes were significantly associated with GNB-BSI (upregulated genes enriched in inflammatory pathways and downregulated genes enriched in oxidative phosphorylation). Twenty-one identified genes were associated with GPC-BSI (downregulated genes associated with cell adhesion molecules and upregulated genes involved in PI3K-Akt signaling). Nineteen genes were common to both groups, with distinct pathogen sensitivities. Patients with GNB-BSI presented with significantly greater disease severity, systemic inflammation and lymphopenia than patients with GPC-BSI. Conversely, patients with GPC-BSI had higher S100A12 and globulin levels and platelet counts. The combination of S100A12high and procalcitonin (PCT)low discriminated GPC-BSI from GNB-BSI (area under the curve=0.882, sensitivity 75%, specificity 91%; cutoff value 0.56).

    CONCLUSION: ScRNA-seq reveals the heterogeneity of GPC-BSI and GNB-BSI. Compared with GPC-BSI, GNB-BSI causes severe inflammation and metabolic suppression, which are associated with poor outcomes. The S100A12high+PCTlow combination may have potential to discriminate among the major causes of BSI.

    Diagnostic value of mismatch-negativity and P3a event-related potentials for sepsis-associated encephalopathy in non-sedated patients: a pilot study
    Zengzheng Ge, Xin Lu, Shiyuan Yu, Mubing Qin, Chao Gong, Qun Xu, Yanxia Gao, Joseph Harold Walline, Huadong Zhu, Yi Li
    2026, 17(2):  172-178.  doi:10.5847/wjem.j.1920-8642.2026.034
    Abstract    HTML    PDF (437KB)   

    BACKGROUND: Although the Confusion Assessment Methods for the Intensive Care Unit (CAM-ICU) is a recommended tool for diagnosing sepsis-associated encephalopathy (SAE), it has several limitations. Mismatch-negativity (MMN) and P3a are components of event-related potentials (ERPs) used with electroencephalography (EEG) and are associated with cerebral function changes in critically ill patients. This study aimed to provide a quantitative, non-invasive method to guide SAE diagnosis in non-sedated patients.

    METHODS: From January 2022 to March 2023, sepsis patients without sedation were enrolled and assessed via the CAM-ICU, Glasgow Coma Scale (GCS), and ERP under standard procedures. Both MMN and P3a data were collected. The diagnostic value of MMN and P3a was assessed with processed ERP data.

    RESULTS: Thirty-six patients were included in this study, comprising 19 patients with SAE and 17 patients without SAE (NSAE). MMN and P3a amplitudes decreased, and only FzMMN amplitude significantly decreased in SAE patients (2.03 [1.08, 2.93] mV vs. 3.21 [1.92, 4.34] mV, P=0.040). After median dichotomization, low F3P3a and FzP3a amplitudes were associated with higher CAM-ICU positivity rates and APACHE II scores. Both amplitude in F3P3a (AUC=0.710, 95%CI: 0.527-0.893, P=0.034) and FzP3a (AUC=0.700, 95%CI: 0.519-0.881, P=0.041) exhibited moderate diagnostic efficacy for SAE, while FzMMN amplitude lacks effective diagnostic value.

    CONCLUSION: In this pilot study, ERP components F3P3a and FzP3a amplitudes demonstrated moderate diagnostic value for SAE. These exploratory findings require confirmation in larger and powered cohorts.

    Research Letter
    Inflammatory and metabolic mediators of acute carbon monoxide poisoning: a Mendelian randomization study Open Access
    Hongsen Ji, Liqiang Zhao, Jingchun Han, Wei Li, Li Pang
    2026, 17(2):  179-183.  doi:10.5847/wjem.j.1920-8642.2026.028
    Abstract    HTML    PDF (1553KB)   
    Viewpoint
    Improving manual cardiopulmonary resuscitation quality in resource-limited settings: an overlooked yet crucial challenge before advanced interventions Open Access
    Longfei Pan, Honghong Pei, Zhengliang Zhang, Jie Liu, Yu Shi, Hai Wang, Xin Hong, Yang Zhou, Changwei Ke, Yang Zhao, Junhua Lyu, Junjie Liang, Jinming Huang, Xiaokun Xi, Xiaodu Li, Jingjing Zhang, Kai Liu
    2026, 17(2):  184-186.  doi:10.5847/wjem.j.1920-8642.2026.032
    Abstract    HTML    PDF (674KB)   
    Case Letters
    Successful treatment of a case of paraganglioma presenting Takotsubo syndrome Open Access
    Ruojie Zhu, Hong Liu, Wen Han, Mao Zhang
    2026, 17(2):  187-189.  doi:10.5847/wjem.j.1920-8642.2026.014
    Abstract    HTML    PDF (941KB)   
    A case report of atypical type E botulism Open Access
    Huanling Li, Hua Xu, Weihua Hao, Huiying Zhao, Yanling Dong, Hui Meng, Hongmei Bai, Yingping Tian, Zhihong He
    2026, 17(2):  190-192.  doi:10.5847/wjem.j.1920-8642.2026.013
    Abstract    HTML    PDF (336KB)   
    Multidisciplinary collaborative management of vertebral artery dissection in a young male: a case report Open Access
    Huan Zhang, Lei Zhang, Linjuan Sun, Ye Huang
    2026, 17(2):  193-195.  doi:10.5847/wjem.j.1920-8642.2026.017
    Abstract    HTML    PDF (1900KB)   
    Gastric volvulus--a rare but potentially fatal mimicker of gastroenteritis: a case report Open Access
    Alston Guan Jie Ong, Jean Mui Hua Lee
    2026, 17(2):  196-198.  doi:10.5847/wjem.j.1920-8642.2026.016
    Abstract    HTML    PDF (551KB)   
    A case report of brain abscess caused by Nocardia cyriacigeorgica identified by metagenomic next-generation sequencing Open Access
    Wenqing Tu, Peiting Zeng, Zhuangtian Wu, Zuyong Li, Tao Yu, Wenxian Zhang, Ran Chen, Lian Liang
    2026, 17(2):  199-201.  doi:10.5847/wjem.j.1920-8642.2026.019
    Abstract    HTML    PDF (1273KB)   
    Acute eosinophilic pneumonia induced by amiodarone: a rare case with early-onset Open Access
    Lin Zhang, Tianci Zhang, Min Zhou, Jian Chen
    2026, 17(2):  202-204.  doi:10.5847/wjem.j.1920-8642.2026.031
    Abstract    HTML    PDF (1291KB)   
    Clinical Imaging and Technique
    The utility of the trans-splenic retrocardiac view in supine critically ill patients Open Access
    Issac Cheong, Pablo Martín Merlo, Francisco Marcelo Tamagnone
    2026, 17(2):  205-206.  doi:10.5847/wjem.j.1920-8642.2026.018
    Abstract    HTML    PDF (500KB)